New Hampshire Insurance Laws and Regulations
Tab A - Outline of Current Rate Review Process Tab B - Summary of Impact of Significant ACA Provisions Tab C - Comparison of Regulatory Provisions by License Tab D – Comparison of Regulatory Provisions by Market
Steven J. Lauwers and Adam C. Varley
7/30/2012
July 30, 2012
Tab A
Outline of Current Rate Review Process
July 30, 2012
Tab A - 1
HMO
Group
Individual/Franchise (as defined in RSA 415:19) (coverages include hospital, surgical and medical expense and “limited benefit”; e.g., disability, accident only, etc.): HMO, HSC, A&H license types
Accident & Health
Insurer
Health Service
Corporation
Large Group: all license types but MEWA
Small Group: all license types but MEWA
Group Supplemental: A&H license only
Qualified Association
Trust/Qualified Purchasing Alliance
RSA 420-B:8 RSA 415:1 RSA 420-A:8 RSA 420-G:10 RSA 420-M (for QPA)
Lice
nse
Type
Re
view
Au
thor
ity
Mar
ket S
egm
ent/
Prod
uct
Blanket (as defined in RSA 415:18, I-a): all license types but MEWA
Ins 3100 Ins 4101 Ins 4104
Ins 3100 Ins 4101 Ins 4103
Ins 3100 Ins 4101 Ins 4106
Ins 3100, Ins 4101 Ins 4102 (hospital, surgical medical expense coverage) Ins 4106 (“limited benefit”)
Ins 3100 Ins 4101 Ins 4106
Spec
ific
Rate
Re
quire
men
ts
Stop Loss (RSA 415-H): A&H license only
Ins 3100 Ins 4101 Ins 4105 Ins 4400
Long-Term Care (RSA 415-D): all license types
Medicare Supp (RSA 415-F): all license types
Ins 3100 Ins 4101 Ins 4106
RSA 415-F:4 Ins 3100 Ins 4101 Ins 4106
MEWA
420-G:3, 13 (re small group; but see discussion below )
July 30, 2012
Tab A - 2
Rela
ted
Form
Rev
iew
Pro
visio
ns
RSA 415:18 RSA 415-A RSA 417-E RSA 420-G:4 RSA 420-G:7 RSA 420-G:12 RSA 420-J Ins 401 Ins 1900: 1901.06(a)(8), (b), (c), (d), (f), (g); 1904; 1906; 1907
RSA 415:18 RSA 415-A RSA 417-E RSA 420-G:4 RSA 420-G:5 RSA 420-G:12 RSA 420-G:13 RSA 420-J Ins 401 Ins 1900: 1901.06(a)(8), (b), (c), (d), (f), (g); 1904; 1906; 1907
RSA 415:18 RSA 415-A RSA 417-E RSA 420-J Ins 401 Ins 1900: 1901; 1904 (for limited products)
RSA 415:6 – 6-q RSA 415:19 RSA 415-A RSA 420-J Ins 401 Ins 1901
RSA 415:18 RSA 415-A RSA 417-E RSA 420-J Ins 401 Ins 1900: 1901.06(a)(8), (b), (c), (d), (f), (g); 1904; 1906; 1907
Ins 401 RSA 415-D:5 through 10 RSA 420-J Ins 3600
RSA 415-F:3, 5, 6 and 7 RSA 420-J Ins 1903 Ins 1905
MEW
A Pr
ovisi
ons
MEWAs are not subject to rate review to the same extent as other insurers. Certain licensed MEWAs (e.g., those not qualified under RSA 415-E:2, II) are subject to rate review as to any small group members per RSA 420-G:3 and RSA 420-G:13. In addition, MEWAs subject to licensure (i.e., those not qualified under RSA 415-E:2, II) must: (1) file an application that, among other things, must provide evidence that the MEWA will be operated in accordance with sound actuarial principles (RSA 415-E:4, VII); (2) submit forms for approval (RSA 415-E:8); (3) annually report on its financial condition to the Commissioner (RSA 415-E:11, I); and (4) triennially provide an actuarial report to the Commissioner. However, none of the foregoing requirements (including licensure) apply to a MEWA that meets certain basic eligibility requirements and (i) is administered primarily from a principal place of business in NH, (ii) has provided employee health benefits for a continuous period of 10 or more years, (iii) maintains a termination liability fund where the fund balance and liabilities of the MEWA are not less than 40% of aggregate billed premium during the prior 6 months and (iv) files an annual report with the Commissioner regarding the termination fund that is certified by a NH CPA. It thus appears that a qualified MEWA is not subject to rate review at all (i.e., that it is not sufficiently regulated to be subject to RSA 420-G:13).
Pref
erre
d Pr
ovid
er
Agre
emen
ts Chapter 420-C governs agreements between health care insurers and preferred providers. Chapter 420-C does not have any rate review
implications, and preferred provider agreements are neither a license category nor a market segment/product. Nonetheless, a reference to it is included here because it relates to, and in large part duplicates, other existing provisions (e.g., RSA 415 and RSA 420-J).
July 30, 2012
Tab A - 3
Sum
mar
y of
cite
d st
atut
ory
and
regu
lato
ry p
rovi
sions
Statutory provisions: RSA 415:6 through 6-q – A&H individual form provisions (see also RSA 420-A for health service corps. and RSA 420-B for HMOs) RSA 415:18 – A&H group form provisions (see also RSA 420-A for health service corps. and RSA 420-B for HMOs) RSA 415:19 – franchise provisions RSA 415-A – Standards for A&H insurance RSA 415-D – Long-term care insurance act RSA 415-E – MEWAs RSA 415-F – Medicare supplemental insurance RSA 417-E – Coverage for certain biologically-based mental illnesses RSA 420-G – Portability, availability and renewability of health coverage RSA 420-J – Managed care Regulatory provisions: Ins 410 – General rate and form review standards Ins 1900 – Standards for A&H insurance 1901 – Minimum standards for A&H insurance 1903 – Medicare supplement insurance 1904 – Group coordination of benefits 1905 – Minimum standards for Medicare supplement insurance 1906 – Discontinuance and replacement of group A&H 1907 – Nondiscrimination in group market 1908 – Coverage for individuals under age 19 Ins 3100 – Electronic rate filing requirements Ins 3600 – Stop loss insurance Ins 4101 – Rate filing requirements for all products Ins 4102 – Rate filing requirements for individual insurance Ins 4103 – Rate filing requirements for small group insurance Ins 4104 – Rate filing requirements for large group insurance Ins 4105 – Rate filing requirements for stop loss insurance Ins 4106 – Rate filing requirements for “limited benefit” insurance
July 30, 2012
Tab A - 4
Sum
mar
y of
Rel
evan
t Ins
uran
ce D
epar
tmen
t Bul
letin
s
All license types/markets: INS 07-063-AB (2007) – Mandatory use of SERFF and EFT for all filings All comprehensive/major medical: INS 10-042-AB (2010) – Compliance with PPACA changes effective September 23, 2010 INS 09-038-AB (2009) – Preexisting condition exclusion standards INS 08-067-AB (2008) – Categories of coverage bulletin INS 08-033-AB (2008) – Filing policy forms and endorsements under RSA 415:1 Group: INS 10-008-AB (2010) – Clarification/further guidance regarding PEOs INS 08-079-AB (2009) – Guidance regarding PEOs INS 09-017-AB (2009) – Effect of Federal Stimulus Act on NH continuation coverage requirements INS 07-064-AB (2007) – Implementation of extended coverage for divorced spouses INS 02-004-AB (2002) – Small group underwriting requirements Individual: INS 10-041-AB (2010) – Guaranteed issue in individual market for children under 19 INS 07-068-AB (2007) – Medical underwriting in the individual market Medicare Supplement: INS 10-005-AB (2010) – Impact of MIPPA on Med Supp rates and filings INS 06-039-AB (2006) – Med Supp rate standards INS 05-048-AB (2007) – Med Supp rate/issue standards “Limited Benefit”: INS 09-067-AB (2010) – Guidelines for accident only coverage INS 08-081-AB (2009) – Guidelines for hospital and limited indemnity insurance INS 08-024-AB (2008) – Limited benefit policies
July 30, 2012
Tab B
Summary of Impact of Significant ACA Provisions
July 30, 2012
Tab B - 1
Patient Protection and Affordable Care Act (“ACA”)
Significant Coverage/Rate Provisions Affecting New Hampshire Insurance Law Summary of Provision Effective Date Codification Impact on NH Law Prohibition on lifetime limits and restriction on annual limits for essential health benefits (becomes prohibition effective January 1, 2014)
Currently effective 42 U.S.C. § 300gg-11 Preempts state law where inconsistent (no expressly inconsistent provisions)
Prohibition on rescissions except for fraud or misrepresentation
Currently effective 42 U.S.C. § 300gg-12 Preempts state law where inconsistent (no expressly inconsistent provisions)
Requirement to provide certain preventive health services without cost sharing
Currently effective 42 U.S.C. § 300gg-13 Preempts state law where inconsistent (no expressly inconsistent provisions); NH could impose more stringent provisions
Extension of dependent coverage until age 26
Currently effective 42 U.S.C. § 300gg-14 (and implementing regulations)
Requires NH insurers to cover dependents until age 26 without condition (NH law amended to conform; See RSA 415:5(3)(a); 420-A:10-a, I; 420-B:8-aa, I; 420-C:4-a, I; 420-J:-d, I)
July 30, 2012
Tab B - 2
Summary of Provision Effective Date Codification Impact on NH Law Requires plans to report on quality improvement and to provide rebates to members if medical loss ratio is (a) less than 85% in the large group market or (b) less than 80% in the small group or individual markets
Currently effective 42 U.S.C. § 300gg-17, 18 (and implementing regulations)
Preempts state law where inconsistent; states can impose more stringent requirements/NHID amended Ins 4100 to incorporate federal definitions of MLR/Ins 4100 remains distinct in some respects (i.e., prospective nature); NH obtained adjustment of 72% in 2011 and 75% in 2012 for individual market, with 80% statutory level to apply in 2013
Permits the offering of student insurance, defines it as a type of individual insurance and exempts it from certain requirements of the Public Health Service Act
Currently effective 42 U.S.C. § 18118 (and implementing regulations)
Preempts state law where inconsistent (NH law currently treats student insurance as group coverage, see RSA 415:19-a)
July 30, 2012
Tab B - 3
Summary of Provision Effective Date Codification Impact on NH Law Requires establishment of Medicare shared savings program utilizing “accountable care organizations,” and establishing accountable care organization eligibility
Currently effective 42 U.S.C. 1395jjj (and implementing regulations)
Permits providers to join together to provide coordinated care; raises questions about regulatory role of NHID
Plans that cover emergency services must provide such coverage without prior authorization, regardless of participating status of provider, and at in-network cost-sharing level
Currently effective 42 U.S.C. 300gg-19a(b) Preempts state law where inconsistent (no expressly inconsistent provision; Bulletin 08-029 addresses emergency services but only regarding charges for emergency services not provided at facilities not licensed as hospital emergency facilities; RSA 420-B:8-n currently provides that POS plans must cover out-of-network emergency services as if they were provided in-network)
July 30, 2012
Tab B - 4
Summary of Provision Effective Date Codification Impact on NH Law Requires that if the designation of a PCP for a child is required, the person be permitted to designate a physician who specializes in pediatrics as the PCP if provider is in-network
Currently effective 42 U.S.C. 300gg-19a(c) Preempts state law where inconsistent (no expressly inconsistent provision)
Prohibits authorization or referral requirements for OB/GYN care provided by in-network providers who specialize in obstetrics or gynecology
Currently effective 42 U.S.C. 300gg-19a(d) Preempts state law where inconsistent (no expressly inconsistent provision)
Plans must provide uniform explanation of coverage documents and standardized definitions to members and applicants
Effective 9/23/12 42 U.S.C. § 300gg-15 (and implementing regulations)
Preempts state law to the extent federal law is stricter; states may impose more stringent requirements
Prohibits the imposition of preexisting condition limitations
Effective 1/1/14 42 U.S.C. § 300gg-3 Would preempt inconsistent NH law (e.g., RSA 420-G:7; RSA 415-A:5, Ins 1907, etc.)
July 30, 2012
Tab B - 5
Summary of Provision Effective Date Codification Impact on NH Law Limits rating factors for small group and individual coverage to (i) whether coverage is for individual or family, (ii) rating area, (iii) age (by no more than 3 to 1) and (iv) tobacco use (by no more than 1.5 to 1); standards apply to large group if permitted to be offered through exchange
Effective 1/1/14 42 U.S.C. § 300gg Will preempt inconsistent NH law (e.g., permissive use of health status as rating factor for individual coverage, permissive use of industry classification as rating factor for small group, age rate factors of 4 to 1 and 3.5 to 1, See RSA 420-G:4)
Coverage offered in individual and group markets must be guaranteed issue and guaranteed renewable
Effective 1/1/14 42 U.S.C. § 300gg-1, gg-2 Will preempt inconsistent NH law (e.g., any inconsistent provisions in RSA 420-G:6, V)
Prohibits the establishment by plans in the individual or group markets of rules for eligibility based on health status factors (except for permitted wellness plans)
Effective 1/1/14 42 U.S.C. § 300gg-4 Will preempt inconsistent NH law (e.g., medical underwriting for individual coverage in RSA 420-G:5)
July 30, 2012
Tab B - 6
Summary of Provision Effective Date Codification Impact on NH Law Coverage in individual and small group markets must include essential health benefits
Effective 1/1/14 42 U.S.C. § 300gg-6 HHS has not issued rules on essential health benefit standards; HHS has indicated its approach will be to use a benchmark plan (chosen by state or, if no choice, defaults to small group plan with largest enrollment); states will be required to defray costs associated with state mandates for exchange-based coverage beginning in 2016
Group plans cannot impose a waiting period longer than 90 days
Effective 1/1/14 42 U.S.C. § 300gg-7 Will preempt inconsistent NH law (e.g., possibly RSA 420-G:2, XVII, which does not include a limit)
Group and individual policies must provide coverage for participation in, and costs of, certain clinical trials
Effective 1/1/14 42 U.S.C. § 300gg-8 Will preempt inconsistent NH law
July 30, 2012
Tab B - 7
Summary of Provision Effective Date Codification Impact on NH Law Defines “qualified health plan” and “essential health benefits” (e.g., for purposes of coverage offered through exchanges)
Effective 1/1/14 42 U.S.C. § 18021; 18022 (and implementing regulations or guidance)
Will determine what coverage can be offered through exchanges (see discussion of exchanges below); will determine minimum coverage that must be offered for all policies (see discussion of essential health benefits above)
Establishes requirements for creation of exchanges and participation in exchanges
Effective 1/1/14 42 U.S.C. § 13031; 18032; 18033; 18041 (as well as provisions regarding eligibility determinations, premium tax credits and mandates and related implementing regulations)
NH has elected not to establish an exclusively state-based exchange; the impact on NH depends upon whether there will be an exclusive federal exchange or a federal/state partnership exchange pursuant to HB 1297
Tab C
Comparison of Applicable New Hampshire
Statutes/Regulations by License/Authority Type
Tables
Table I – Provisions applicable to accident and health insurers generally Table II – Provisions applicable to health service corporations
Table III – Provisions applicable to HMOs Table IV – Provisions applicable to Qualified Association Trusts
Table V – Provisions applicable to Qualified Purchasing Alliances Table VI – Provisions applicable to MEWAs
Table VII – Applicability of regulatory rate review provisions
Color Key for Tables Common provision Similar provision No corresponding provision Ambiguity
July 30, 2012
Tab C, Table I - 1
Table I – Comparison of provisions of other chapters corresponding to RSA 415/A&H Insurers Generally RSA 415: Provisions governing A&H insurers generally http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415.htm
RSA 420-A: (HSC) Applicability of A&H provision/corresponding provision http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-A.htm
RSA 420-B: (HMO) Applicability of A&H provision/corresponding provision http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-B.htm
RSA 420-G:10: Qualified Association Trust http://www.gencourt.state.nh.us/rsa/html/XXXVII/420-G/420-G-10.htm
RSA 420-M: Qualified Purchasing Alliance http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-M.htm
RSA 415-E: MEWAs http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-E.htm
400-A:32 – Premium tax http://www.gencourt.state.nh.us/rsa/html/XXXVII/400-A/400-A-32.htm
Applies (except as limited by 420-A:27)
Applies (except as limited by 420-B:17)
Does not apply? Does not apply Applies?
400-A:36 – Annual statement http://www.gencourt.state.nh.us/rsa/html/XXXVII/400-A/400-A-36.htm
See 420-A:20 See 420-B:9 Does not apply? Does not apply See 415-E:11
July 30, 2012
Tab C, Table I - 2
400-A:37 – Examinations http://www.gencourt.state.nh.us/rsa/html/XXXVII/400-A/400-A-37.htm
See 420-A:20 See 420-B:10 Does not apply? Does not apply See 415-E:11, 12
401 (Incorp. and powers of ins. comp.) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-401.htm
Does not apply (but see certain related corresponding provisions in Table B)
Does not apply (but see certain related corresponding provisions in Table B)
Does not apply? Does not apply Applies?
401-B – Holding companies http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-401-B.htm
Applies Applies Does not apply Does not apply Does not apply
402 – Ins. comp. and agents http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-402.htm
Does not apply Does not apply Does not apply? Does not apply Applies?
402-C – Rehab and Liquidation http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-402-C.htm
Applies Applies Does not apply? Does not apply Applies (per 415-E:15)
July 30, 2012
Tab C, Table I - 3
402-J http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-402-J.htm
Applies Applies Applies Applies (to extent producers are utilized)
Applies
404-F – Risk based capital http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-404-F.htm
Applies Applies Does not apply? Does not apply Applies?
404-G – Individual high risk pool http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-404-G.htm
Applies Applies Does not apply? Does not apply Does not apply?
408-B – L&H GA http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-408-B.htm
Does not apply? Does not apply Does not apply? Does not apply Does not apply?
415 http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415.htm
415:1 – Filing policies and rates
420-A:8 420-B:8 420-G:10 420-G:10 415-E:8 (as to forms only); 420-G (as to small group rates only)
July 30, 2012
Tab C, Table I - 4
415:2 – Disapproval of forms
420-A:8 420-B:8 420-G:10 420-G:10 415-E:8
415:3 – Subsequent disapproval
None None None None 415-E:8
415:4 – Review of disapproval
420-A:23 420-B:14 None None None
415:5 – Form of policy
420-A:10-a (as to para. I(3), (3-a)(a)); 420-A:15-b (as to para. I(3-a)(b))
420-B:8, III-b (as to para. I(3-a)(a)); 420-B:8-q (as to para. I(3-a)(b)); 420-B:8-aa (as to para. I(3))
420-J:8-d (as to para. I(3),(3-a)(a)); 420-J:6-d (as to para. I(3-a)(b))
None 420-J:8-d (as to para. I(3),(3-a)(a)); 420-J:6-d (as to para. I(3-a)(b))
415:6 – Policy provisions
420-A:2 (as to para. II(4) only)
420-B:8, III-c (as to para. II(4) only); 420-B:8-I (as to para. I(2))
None? None (may apply to coverage obtained)
None?
415:6-a – Welfare recipients
415-A:2-a 415-A:2-a None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None?
415:6-aa – 90-day supply of drugs
420-J:7-b, VIII 420-J:7-b, VIII 420-J:7-b, VIII? None (may apply to coverage obtained)
None?
415:6-b – Coverage of psychiatric and psychological servs
None 420-B:8-b, II None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None?
415:6-c – Coverage of enteral formulas
420-A:17 420-B:8-ff None None (may apply to coverage obtained)
None
415:6-d – Maternity rider
420-A:9, III 420-B:8, III-a None None (may apply to coverage obtained)
None
415:6-e – Coverage of diabetes servs and supplies
420-A:17-a 420-B:8-k None None (may apply to coverage obtained)
None
July 30, 2012
Tab C, Table I - 5
415:6-f – Patients’ bill of rights
420-A:16-a 420-B:8-m None None (may apply to coverage obtained)
None
415:6-g – Off-label prescription drugs
420-A:2 420-B:20, III None None (may apply to coverage obtained)
None
415:6-h – Prompt payment
420-A:17-d 420-J:8-a None None (may apply to coverage obtained)
None
415:6-I – Retro denials prohibited
420-A:17-e 420-J:8-b None None (may apply to coverage obtained)
None
415:6-j – Coverage of prosthetic devices
None None None None None
415:6-k – Prescription drug info cards
420-A:2 420-J:7-b, V None None (may apply to coverage obtained)
None
415:6-l – Coverage for midwives (individual)
420-A:17-f 420-B:8-p None None (may apply to coverage obtained)
None
415:6-m – Coverage for testing for bone marrow donations
420-A:2 420-B:20, III None None (may apply to coverage obtained)
None
415:6-n – Coverage of children’s early intervention therapy
420-A:17-g 420-B:8-r None None (may apply to coverage obtained)
None
415:6-o – Coverage for obesity and morbid obesity (individual)
420-A:2 420-B:20, III None None (may apply to coverage obtained)
None
415:6-p – Coverage for hearing aids
None None None None None
July 30, 2012
Tab C, Table I - 6
415:6-q – Reimbursement for ambulance service providers
415:6-q (by virtue of 420-G:2, IX)
415:6-q (by virtue of 420-G:2, IX)
None None None
415:7 – Conforming to statute
None None None? None None?
415:8 – Exceptions (for policies issued until 1956)
None None None? None None?
415:9 – Falsity in application
None None None? None None?
415:10 – Acknowledgement of notice (not acting as waiver of insurer’s rights)
None None None? None None?
415:11 – Alteration of application (not permitted except with consent of applicant)
None None None? None None?
415:12 – By insurer (alteration by officer deemed alteration by insurer)
None None None? None None?
July 30, 2012
Tab C, Table I - 7
415:13 – Age limit (coverage continues for premium period, except only refund required upon misstatement of age)
None None None None None
415:14 – Non-app to certain policies (workers’ comp, reinsurance, group/blanket and life ins./annuities)
None equivalent (but 420-A:30 provides that fraternals and life companies are excepted and 420-A:32 provides that workers’ comp laws are not affected by chapter)
None None? None None?
415:15 – Discrimination
417, VIII 417, VIII 417, VIII? None 417, VIII?
415:16 – Approval by Commissioner (of policies supplemental to life/annuities providing certain A&H benefits)
None None None? None None?
415:17 – Fraternals (non-applicability of chapter)
420-A:30 None None? None None?
415:18 – Group/blanket provisions
July 30, 2012
Tab C, Table I - 8
Para. I – general provisions
420-A:10 (as to para. I(q))
420-B:12, IV (as to para. I(q)); 420-B:8-i (as to para. I(r)); 420-B:8, III-a (as to para. I(s))
None (may apply to coverage obtained)?
None None (may apply to coverage obtained)?
Para. I-a – blanket ins.
None None None None None
Para. I-b – non-assignment of blanket benefits
None None None None None
Para. II – disclosure of reductions and exceptions to coverage
420-A:9, II 420-B:8, III(b) None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
Para. III – Approval of form with modified provisions
None None None (may apply to coverage obtained)?
None None (may apply to coverage obtained)?
Para. IV – Coverage for dependents; direct payment to provider
See 420-A:10-a; 420-A:9, XIII
See 420-B:8-aa None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
Para. V – Dependent mentally or physically incapable of earning living
420-A:2; 420-A:10-a, I-a
420-B:8, III-b 420-J:6-d 420-J:8-d?
None (may apply to coverage obtained)
420-J:6-d 420-J:8-d?
Para. VI – Coverage for services provided by doctor of osteopathy, chiropractic, etc.
None None None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
July 30, 2012
Tab C, Table I - 9
Para. VII – Option to elect coverage through high risk pool or continuation coverage upon term. of group cov.
420-A:2 (as to subpara. (g) only)
420-B:20, III (as to subpara. (g) only)
None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
Para. VII-a – Coverage in event of strike, lockout or other labor dispute
420-A:2 420-B:20, III None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
Para. VII-b – coverage for divorced spouses
None None None (may apply to coverage obtained)?
None None (may apply to coverage obtained)?
Para. VIII – Definition of physician or doctor to include dentist
None None None (may apply to coverage obtained)?
None None (may apply to coverage obtained)?
Para. XII – No denial of coverage based on health risk or condition except permitted pre-ex condition exclusions
420-A:9, IX 420-B:12, VI 420-G:10(b); 420-G:7
420-G:10(b); 420-G:7
420-G:10(b); 420-G:7
Para. XIII –Allocation of costs of maternity and childbirth
420-A:9, X 420-B:12, VII None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
Para. XIV – Patients bill of rights
420-A:16-a 420-B:8-m None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
July 30, 2012
Tab C, Table I - 10
Para. XV – Definitions for continuation coverage
Implied by 420-A:2 Implied by 420-B:20, III
None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
Para. XVI – Continuation coverage
420-A:2 420-B:20, III None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
Para. XVII – Term. of coverage
420-A:2 420-B:20, III None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-a – Coverage for mental/nervous conditions
420-A:2 420-B:8-b None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-b – Cancellation/non-renewal
420-A:11 420-B:8-c None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-d – Coverage for scalp hair prostheses
420-A:14 420-B:8-f None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-e – Coverage for enteral formulas
420-A:17 420-B:8-ff None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-f – Coverage for diabetes servs/supplies
420-A:17-a 420-B:8-k None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-g – Coverage for dental (medical/hospital)
420-A:17-b 420-B:8-ee None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
July 30, 2012
Tab C, Table I - 11
415:18-i – Coverage for contraceptives
420-A:17-c 420-B:8-gg None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-j – Off-label prescription drugs
420-A:2 420-B:20, III None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-k – Prompt payment
420-A:17-d 420-J:8-a None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-l – Coverage for clinical trials
415:18-l 415:18-l None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-m – Retro denials prohibited
420-A:17-e 420-J:8-b None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-n – Coverage for prosthetic devices
415:18-n 415:18-n None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-o – Prescription drug info. Cards
420-A:2 420-J:7-b, V None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-p – Coverage of court-ordered servs
420-A:15-a 420-B:8-o None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-q – Coverage for midwives
420-A:17-f 420-B:8-p None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-r – Coverage for testing for bone marrow donations
420-A:2 420-B:20, III None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
July 30, 2012
Tab C, Table I - 12
415:18-s – Coverage for children’s early intervention servs
420-A:17-g 420-B:8-r None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-t – Coverage for obesity/morbid obesity
420-A:2 420-B:20, III None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-u – Coverage for hearing aids
420-A:2 420-B:20, III None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:18-v – Reimbursement of ambulance serv providers
420-A:2 420-B:20, III None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:19 – Franchise plan
None None None None None
415:19-a – Student insurance
None None None None None
415:20 – Penalty Multiple (see 417; 420-J:14; 420-G:16)
420-B:13 None 420-M:3 415-E:14
415:21 – Ins. through joint action
None None None None None
415:22 – Newborn children
420-A:2 420-B:8-j None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:22-a – Coverage during adoption proceeding
420-A:15 420-B:8-g None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
415:22-b – Notice of allowable benefit
420-A:16 420-B:8-h None (may apply to coverage obtained)?
None (may apply to coverage obtained)
None (may apply to coverage obtained)?
July 30, 2012
Tab C, Table I - 13
415:23 – Jurisdiction over health insurers
None None None None None
415:24 – Rate modifications
None None None None None
415-A – Standards for A&H Ins. http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-A.htm
Applies Applies Applies? Does not apply Applies
415-D – Long Term Care Insurance http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-D.htm
Applies Applies Applies? Does not apply Applies?
415-F – Med. Supp. Ins. http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-F.htm
Applies Applies Applies? Does not apply Does not apply?
417 – Unfair ins. trade practices http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-417.htm
Applies Applies Applies? Does not apply Applies?
July 30, 2012
Tab C, Table I - 14
417-E – Coverage for certain mental illness http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-417-E.htm
Applies Applies Does not apply directly (may apply to coverage obtained)?
Does not apply directly (may apply to coverage obtained)
Applies?
417-F – Coverage for emergency services http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-417-F.htm
Applies Applies Applies? Does not apply directly (may apply to coverage obtained)
Applies?
420-C – Preferred provider agts. http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-C.htm
Applies Applies? Does not apply? Does not apply Does not apply?
420-G – Portability, availability, renewability http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-G.htm
Applies Applies Applies (to the extent provided in 420-G:10)
Applies (to the extent provided in 420-G:10)
Applies (to the extent provided in 420-G:3)
July 30, 2012
Tab C, Table I - 15
420-H – EOB http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-H.htm
Applies Applies Does not apply directly (may apply to coverage obtained)?
Does not apply directly (may apply to coverage obtained)
Does not apply directly (may apply to coverage obtained)?
420-I – Prohibition on exclusive managed care arrangements http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-I.htm
Applies Applies Applies? Does not apply directly (may apply to coverage obtained)
Applies?
420-J – Managed care law http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-J.htm
Applies Applies Applies? Does not apply directly (may apply to coverage obtained)
Applies?
July 30, 2012
Tab C, Table II - 1
Table II – Comparison of provisions of other chapters corresponding to 420-A RSA 420-A: (HSC) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-A.htm
RSA 415: Provisions governing A&H insurers generally http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415.htm
RSA 420-B: (HMO) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-B.htm
RSA 420-G:10: Qualified Association Trust http://www.gencourt.state.nh.us/rsa/html/XXXVII/420-G/420-G-10.htm
RSA 420-M: Qualified Purchasing Alliance http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-M.htm
RSA 415-E: MEWAs http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-E.htm
420-A:1 – Definitions No generally applicable definitions provision (but relevant terms are defined elsewhere)
420-B:1 420-G:2, XV (as to “qualified association trust” only)
420-M:2 415-E:1
420-A:2 – Applicable Statutes
See Table A for provisions incorp. by 420-A:2
420-B:20 None No directly applicable provision (but see 420-M:3 regarding jurisdiction generally)
None
420-A:3 – Incorporation
401 No directly applicable provision (but see 420-B:2 and 293-A generally)
None No directly applicable provision (but see 293-A regarding incorp. generally)
No directly applicable provision (but see other incorp. provisions generally)
420-A:4 – License 402:12 420-B:2 None 420-M:4 415-E:4 420-A:5 – Directors (limitations)
None None None None None
420-A:6 – Liability of Directors
401:10 (293-A:8.50 through 293-A:8.58)
293-A:8.50 through 293-A:8.58
None No directly applicable provision (but see 293-A:8.50 through 293-A:8.58 generally)
No directly applicable provision (but see 293-A:8.50 through 293-A:8.58 generally)
420-A:7 – License to Agent
402-J 420-B:18 None? No directly applicable provision (but 402-J would apply to extent producers utilized)
No directly applicable provision (but 402-J would apply to extent producers utilized)
July 30, 2012
Tab C, Table II - 2
420-A:8 – Filing and approval of contracts/rates
415:1, 415:2 420-B:8 420-G:10 (as to rates)
None 420-G:13 (as to small group)
420-A:9 – Contracts with subscribers
See 415:6-d, 415:18 para. II, XII, XIII
420-B:8 None? None 415:18?
420-A:10 – Part-time employees
415:18, I(q) 420-B:12, IV None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18, I(q)?
420-A:10-a – Dependent coverage
415:5, I(3), 415:18, IV, V
420-B:8, III-b, 420-B:8-aa
420-J:8-d? None (may apply to coverage obtained)
415:18, IV, V?
420-A:11 – Cancellation/nonrenewal of group insurance
415:18-b 420-B:8-c None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-b?
420-A:12 – Cancellation/ nonrenewal of individual insurance
415:6, II(8) 420-B:8-d None None (may apply to coverage obtained)
None
420-A:14 – Coverage for scalp hair prostheses
415:18-d 420-B:8-f None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-d?
420-A:15 – Coverage during adoption proceedings
415:22-a 420-B:8-g None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:22-a?
420-A:15-a – Covered, court-ordered services
415:18-p 420-B:8-o 420-J:6-c? None (may apply to coverage obtained)
415:18-p?
420-A:15-b –Coverage for dependents
415:5, I(3-a)(b) 420-B:8-q 420-J:6-d? None (may apply to coverage obtained)
420-J:6-d?
420-A:16 – Notification of allowable benefit
415:22-b 420-B:8-h None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:22-b?
420-A:16-a – Patients’ bill of rights
415:6-f, 415:18, XIV 420-B:8-m None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18, XIV?
420-A:17 – Coverage for enteral formulas
415:6-c, 415:18-e 420-B:8-ff None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-e?
July 30, 2012
Tab C, Table II - 3
420-A:17-a – Coverage for diabetes servs. and supplies
415:6-e, 415:18-f 420-B:8-k None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-f?
420-A:17-b – Coverage for dental procedures
415:18-g 420-B:8-ee None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-g?
420-A:17-c – Coverage for contraceptives
415:18-i 420-B:8-gg None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-i?
420-A:17-d – Prompt payment
415:6-h, 415:18-k 420-J:8-a 420-J:8-a? None (may apply to coverage obtained)
415:18-k?
420-A:17-e – Retro. denials prohibited
415:6-i, 415:18-m 420-J:8-b 420-J:8-b? None (may apply to coverage obtained)
415:18-m?
420-A:17-f – Coverage for midwives
415:6-l, 415:18-q 420-B:8-p None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-q?
420-A:17-g – Coverage for early intervention servs.
415:6-n, 415:18-s 420-B:8-r None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-s?
420-A:18 – Investments (governed by 411-A)
402:28 420-B:15 None? None 402:28?
420-A:19 – Proh. limitations on liability
420-J:8, IV, V (for purposes of managed care contracts)
420-J:8, IV, V 420-J:8, IV, V? None (may apply to coverage obtained)
420-J:8, IV, V
420-A:20 – Reports and Exams
400-A:36, 400-A:36-a, 400-A:37
420-B:9, 420-B:10 None? 420-M:5 415-E:11; 415-E:12
420-A:21 – Reserves No corresponding provision (but see 401:4 for capital requirements generally)
No corresponding provision (but see 420-B:25 for capital requirements generally)
None None No corresponding provision (but see 415-E:5, 6 and 7)
420-A:22 – Annual Review (of rates)
None None None None None
420-A:23 – Appeals RSA 541 420-B:14 RSA 541 RSA 541 RSA 541
July 30, 2012
Tab C, Table II - 4
420-A:24 – Agreements with providers
None None None None None
420-A:25 – Admin services
No directly applicable provision (but see 402-H re TPAs)
No directly applicable provision (but see 402-H re TPAs)
No directly applicable provision (but see 402-H re TPAs)
No directly applicable provision (but see 402-H re TPAs)
No directly applicable provision (but see 402-H re TPAs)
420-A:26 – Nonliability of corp.
None None None None None
420-A:27 – Taxation (premium tax)
400-A:32 (as to premium tax applicability)
420-B:17 None? None 400-A:32 (as to premium tax applicability)?
420-A:28 – Relationship of provider/patient
No directly applicable provision (but see 420-J)
No directly applicable provision (but see 420-J)
No directly applicable provision (but see 420-J)
None No directly applicable provision (but see 420-J)
420-A:29 – Foreign corp.; reciprocity
405 – Foreign ins. companies
420-B:2, I, 420-B:4 No directly applicable provision (but see 293-A generally)
No directly applicable provision (but see 293-A generally)
No directly applicable provision (but see 293-A generally)
420-A:30 – Exceptions (to application of chapter)
415:14 None None None None
420-A:31 – Rules 400-A:15 420-B:21 400-A:15 420-M:3; 400-A:15 415-E:16 420-A:32 – Workers’ comp law not affected
415:14 None None None None
July 30, 2012
Tab C, Table III - 1
Table III – Comparison of provisions of other chapters corresponding to 420-B RSA 420-B: (HMO) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-B.htm
RSA 415: Provisions governing A&H insurers generally http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415.htm
RSA 420-A: (HSC) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-A.htm
RSA 420-G:10: Qualified Association Trust http://www.gencourt.state.nh.us/rsa/html/XXXVII/420-G/420-G-10.htm
RSA 420-M: Qualified Purchasing Alliance http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-M.htm
RSA 415-E: MEWAs http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-E.htm
420-B:1 – Definitions
No generally applicable definitions provision (but relevant terms are defined elsewhere)
420-A:1 420-G:2, XV (as to “qualified association trust” only)
420-M:2 415-E:1
420-B:2 – Certificate of Authority
402:12 420-A:4 None 420-M:4 415-E:4
420-B:3 – Application for COA
402:11 420-A:4 None 420-M:4 415-E:4
420-B:4 – Jurisdictional POA
405:10 None None None None
420-B:5 – Issuance of COA
402:12 420-A:4 None 420-M:4 415-E:4
420-B:5-a – Renewal of COA
402:12 420-A:4 None 420-M:4 415-E:4
420-B:5-b – New license for changed conditions
402:14-a None None None None
July 30, 2012
Tab C, Table III - 2
420-B:6 – Pre-certificate activities
None None None None None
420-B:7 – Powers of HMOs
401; 293-A See 420-A generally None 420-M:7 See 415-E generally
420-B:8 – Forms of evidence of coverage
415:1; 415:2; 415:5, I(3-a)(a) and (b); 415:6, II(4); 415:6-d; 415:18, II, V
420-A:9 420-G:10 (as to approval of rates)
None 415-E:8?
420-B:8-aa – Dependent coverage
415:5, I(3), 415:18, IV 420-A:10-a 420-J:8-d? None (may apply to coverage obtained)
415:5, I(3), 415:18, IV?
420-B:8-b – Coverage for mental and nervous conditions
415:6-b; 415:18-a 415:18-a; 417-E None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:6-b; 415:18-a?
420-B:8-c – Cancellation/nonrenewal of individual coverage
415:6, II(8) 420-A:12 None None (may apply to coverage obtained)
None
420-B:8-d – Cancellation/nonrenewal of group coverage
415:18-b 420-A:11 None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-b?
420-B:8-ee – Coverage for dental procedures
415:18-g 420-A:17-b None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-g?
420-B:8-f – Coverage for scalp hair prostheses
415:18-d 420-A:14 None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-d?
420-B:8-ff – Coverage for enteral formulas
415:6-c, 415:18-e 420-A:17 None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:6-c, 415:18-e?
July 30, 2012
Tab C, Table III - 3
420-B:8-g – Coverage during adoption proceedings
415:22-a 420-A:15 None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:22-a?
420-B:8-gg – Coverage for contraceptives
415:18-i 420-A:17-c None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:18-i?
420-B:8-h – Notification of allowable benefit
415:22-b 420-A:16 None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:22-b?
420-B:8-i – Incontestable provision
415:6, I(2); 415:18, I(r)
None None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:6, I(2); 415:18, I(r)?
420-B:8-j – Newborn children
415:22 415:22 (by 420-A:2) None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:22?
420-B:8-k – Coverage for diabetes servs. and supplies
415:6-e, 415:18-f 420-A:17-a None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:6-e, 415:18-f?
420-B:8-l – Medicare risk contracts
None None None None None
420-B:8-m – Patients’ bill of rights
415:6-f, 415:18, XIV 420-A:16-a None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:6-f, 415:18, XIV?
420-B:8-n – Point of service plans
None None None None None
420-B:8-o – Coverage of covered, court-ordered servs.
415:18-p 420-A:15-a 420-J:6-c? None (may apply to coverage obtained)
415:18-p?
July 30, 2012
Tab C, Table III - 4
420-B:8-p – Coverage of midwives
415:6-l, 415:18-q 420-A:17-f None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:6-l, 415:18-q?
420-B:8-q – Coverage of dependents
415:5, I(3-a)(b); 415:18, V
420-A:15-b 420-J:6-d? None (may apply to coverage obtained)
415:5, I(3-a)(b); 415:18, V?
420-B:8-r – Coverage of early intervention services
415:6-n, 415:18-s 420-A:17-g None (may apply to coverage obtained)?
None (may apply to coverage obtained)
415:6-n, 415:18-s?
420-B:9 – Reports to Commissioner
400-A:36, 400-A:36-a
420-A:20 None? 420-M:5 415-E:11
420-B:10 – Examination
400-A:37 420-A:20 None? 420-M:5 415-E:11; 415-E:12
420-B:11 – Complaint system
420-J:5 (as to managed care)
420-J:5 None? None 420-J:5 (as to managed care)
420-B:12 – Prohibited practices
417 417 None? 420-M:7 417?
420-B:12, V – Any willing pharmacy provider
None None None None None
420-B:13 – Sanctions
Multiple (see, e.g., 415:20, 400-A:14, 400-A:15)
Multiple (see 417; 420-J:14; 420-G:16)
None? 420-M:3 415-E:14
420-B:14 – Procedures and Appeals
RSA 541 420-A:23 RSA 541 RSA 541 RSA 541
420-B:15 – Investments (subject to standards governing life insurers)
402:28 420-A:18 None? None No directly applicable provisions (but see 415-E:5, 6 and 7)
420-B:16 – Fees 400-A:29 400-A:29 None? None 400-A:29? 420-B:17 – Taxation 400-A:32 400-A:27 None? None 400-A:32?
July 30, 2012
Tab C, Table III - 5
420-B:18 – Regulation of agents
402-J 402-J None? No directly applicable provision (but 402-J would apply to extent producers utilized)
402-J?
420-B:19 – Powers of Insurers and hosp. and med. Service corps.
None None None None None
420-B:20 – Stat. construction and relationship to other laws
See Table A for provisions incorp. by 420-B:20
420-A:2 None No directly applicable provision (but see 420-M:3 regarding jurisdiction generally)
None
420-B:21 – Regulations
400-A:15 420-A:31 400-A:15 400-A:15 400-A:15
420-B:22 – Federal legis.
None None None None None
420-B:23 – Systems failing to meet reqs. of chapter (operating and license of system similar to HMO)
None None None None None
420-B:24 Notification of option to enroll in HMO
None None None None None
420-B:25 – Capital reqs.
See 401:4, 404-F 420-A:21 None? None 415-E:5, 6 and 7
July 30, 2012
Tab C, Table IV - 1
Table IV – Comparison of provisions of other chapters corresponding to Qualified Association Trusts RSA 420-G:10: Qualified Association Trust http://www.gencourt.state.nh.us/rsa/html/XXXVII/420-G/420-G-10.htm
RSA 415: Provisions governing A&H insurers generally http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415.htm
RSA 420-A: (HSC) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-A.htm
RSA 420-B: (HMO) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-B.htm
RSA 420-M: Qualified Purchasing Alliance http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-M.htm
RSA 415-E: MEWAs http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-E.htm
420-G:2, XV – Definition of qualified association trust
No generally applicable definitions provision (but relevant terms are defined elsewhere)
420-A:1 420-B:1 420-M:2 415-E:1
420-G:10 – Rating requirements
415:1, 415:2; 420-G 420-A:8; 420-G 420-B:8; 420-G None 420-G:13 (as to small group)
July 30, 2012
Tab C, Table V - 1
Table V – Comparison of provisions of other chapters corresponding to 420-M RSA 420-M: Qualified Purchasing Alliance http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-M.htm
RSA 415: Provisions governing A&H insurers generally http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415.htm
RSA 420-A: (HSC) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-A.htm
RSA 420-B: (HMO) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-B.htm
RSA 420-G:10: Qualified Association Trust http://www.gencourt.state.nh.us/rsa/html/XXXVII/420-G/420-G-10.htm
RSA 415-E: MEWAs http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-E.htm
420-M:1 – Purpose 401:1 None None None None 420-M:2 – Definitions
No generally applicable definitions provision (but relevant terms are defined elsewhere)
420-A:1 420-B:1 420-G:2, XV (as to “qualified association trust” only)
415-E:1
420-M:3 – Jur. of comm.; penalties
Multiple (see 415:1, 415:2, 415:23 as to jurisdiction; see, e.g., 415:20, 400-A:14, 400-A:15 as to penalties)
Multiple (see 420-A:2, 420-A:4 as to jurisdiction; see, e.g., 417; 420-J:14; 420-G:16 as to penalties)
420-B:2 (as to jurisdiction); 420-B:13 (as to penalties)
420-G:10 (as to jurisdiction)
415-E:2 (as to jurisdiction); 415-E:14 (as to penalties)
420-M:4 – Application and licensing
402:11; 402:12 420-A:4 420-B:2; 420-B:3; 420-B:5
None 415-E:4
July 30, 2012
Tab C, Table V - 2
420-M:5 – Business plan and other req. documents
402:11 (regarding application info.)
420-A:4 (regarding application info.)
42-B:3 (regarding application info.)
None 415-E:4 (regarding application info.)
420-M:6 – Revocation of license and insolvency
See, e.g., 415:20, 400-A:14, 400-A:15 as to revocation; 402-C as to insolvency
See, e.g., 415:20, 400-A:14, 400-A:15 as to revocation; 402-C as to insolvency
420-B:13 (as to revocation); 402-C as to insolvency
None 415-E:13 (as to revocation); 402-C as to insolvency
420-M:7 – Powers and duties; restrictions
401:1, 293-A (as to powers); 417 (as to prohibited practices)
420-A generally (as to powers); 417 (as to prohibited practices)
420-B:7 (as to powers); 420-B:12 (as to prohibited practices)
None? 415-E generally (as to powers); 417 (as to prohibited practices)
420-M:8 – Contracts with participating carriers
None None None None None
420-M:9 – Reqs. for participating carriers
None None None None None
420-M:10 – Marketing health benefit plans
No corresponding provision (but see 417 regarding advertising generally)
No corresponding provision (but see 417 regarding advertising generally)
No corresponding provision (but see 420-B:12 regarding advertising generally)
No corresponding provision (but see 417 regarding advertising generally)?
No corresponding provision (but see 417 regarding advertising generally)?
420-M:11 – Conflict of interest
None None None None None
420-M:12 – Distinguished from MEWA
None None None None None (compare to 415-E generally)
420-M:13 – Qualified purchasing alliance
None None None 420-G:2, XV (regarding qualifying criteria)
415-E:3 (regarding qualifying criteria)
July 30, 2012
Tab C, Table VI - 1
Table VI – Comparison of provisions of other chapters corresponding to 415-E RSA 415-E: MEWAs http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415-E.htm
RSA 415: Provisions governing A&H insurers generally http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-415.htm
RSA 420-A: (HSC) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-A.htm
RSA 420-B: (HMO) http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-B.htm
RSA 420-G:10: Qualified Association Trust http://www.gencourt.state.nh.us/rsa/html/XXXVII/420-G/420-G-10.htm
RSA 420-M: Qualified Purchasing Alliance http://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-M.htm
415-E:1 – Definitions
No generally applicable definitions provision (but relevant terms are defined elsewhere)
420-A:1 420-B:1 420-G:2, XV (as to “qualified association trust” only)
420-M:2
415-E:2 – Applicability (certain MEWAs exempt)
None None None None None
415-E:3 – General Eligibility
None None None 420-G:2, XV 420-M:13
415-E:4 – Filing of Application
402:11 420-A:4 420-B:3 None 420-M:4
415-E:5 – Fund Balance
See 401:4, 404-F 420-A:21 420-B:25 None? No corresponding provision (but see 420-M:5, regarding sound financial operation/controls)
July 30, 2012
Tab C, Table VI - 2
415-E:6 – Financial Condition, etc.
404-F 404-F 404-F None? No corresponding provision (but see 420-M:5, regarding sound financial operation/controls)
415-E:7 – Insolvency protection (deposit)
402:73 Deposit required Deposit required None? None
415-E:8 – Policy forms
415:1; 415:2; 415:3 420-A:8 420-B:8 None? None
415-E:9 – Employer participants’ liability
None None None None None
415-E:10 – Term. of arrangement
None None None None None
415-E:11 – Annual/triennial reports
400-A:36, 400-A:36-a
420-A:20 420-B:9 None? 420-M:5
415-E:12 – Place of business; maintenance of records
400-A:37, III(b) (as to availability of records only)
420-A:20 (as to availability of records only)
420-B:10, II (as to availability of records only)
None? 420-M:5 (as to availability of records only)
415-E:13 – Susp., revoc. \of approval
Multiple (see, e.g., 415:20, 400-A:14, 400-A:15)
Multiple (see 417; 420-J:14; 420-G:16)
420-B:13 None 420-M:6
415-E:14 – Penalties Multiple (see, e.g., 415:20, 400-A:14, 400-A:15)
Multiple (see 417; 420-J:14; 420-G:16)
420-B:13 None? 420-M:3
415-E:15 – Rehab/diss
402-C 402-C 402-C None? 420-M:6
415-E:16 - Rulemaking
400-A:15 420-A:31 420-B:21 400-A:15 400-A:15
July 30, 2012
Tab C, Table VII - 1
Table VII – Applicability of regulatory provisions regarding rate review A&H Generally HSC HMO Qual. Assoc.
Trust Qual. Purch. Alliance
MEWA
A. Ins 401 (general form/rate review standards) http://www.gencourt.state.nh.us/rules/state_agencies/ins400.html Yes Yes Yes Yes? No (but would apply
as to coverage purchased)
Yes
B. Ins 3100 (electronic rate submission requirements) http://www.gencourt.state.nh.us/rules/state_agencies/ins3100.html Yes Yes Yes Yes? No (but would apply
as to coverage purchased)
Yes (as to small group)?
C. Ins 4100 (specific rate review standards for individual, small group, large group, stop loss and “limited benefit”) http://www.gencourt.state.nh.us/rules/state_agencies/ins4100.html
Yes Yes Yes Yes? No (but would apply as to coverage purchased)
Yes (as to small group)?
D. Ins 1900 (standards governing A&H coverage) http://www.gencourt.state.nh.us/rules/state_agencies/ins1900.html Yes Yes Yes Yes? No Yes
Tab D
Comparison of Rate Review Regulations by Market Segment
July 30, 2012
Tab D - 1
Comparison of Rate Review Provisions by Market Segment Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
1. Ins 401 – Filings for LAH Insurance
401.01 – Purpose and Scope X X X X X X X X 401.02 – Definitions X X X X X X X X 401.03 – Rules applicable to all forms
X X X X X X X X
401.04 – Individual life and annuity contracts
N/A N/A N/A N/A N/A N/A N/A N/A
401.05 – Individual accident and health
N/A N/A N/A X N/A N/A X X
401.06 – Group life policies N/A N/A N/A N/A N/A N/A N/A N/A 401.07 – Group and blanket accident and health
X X X N/A X N/A X X
401.08 – Group annuity contracts
N/A N/A N/A N/A N/A N/A N/A N/A
401.09 – Variable contracts N/A N/A N/A N/A N/A N/A N/A N/A 401.10 – Computation of cash values for variable annuities
N/A N/A N/A N/A N/A N/A N/A N/A
401.11 – Applications X X X X X X X X 401.12 – Forms filing, review and inventory procedures
X X X X X X X X
401.13 – Penalty; generally X X X X X X X X
July 30, 2012
Tab D - 2
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
2. Ins 3100 – Electronic Filing Standards
3101.01 – Purpose X X X X X X X X 3101.02 – Applicability and Scope
X X X X X X X X
3101.03 – Definitions X X X X X X X X 3101.04 – Procedural requirements
X X X X X X X X
3. Ins 4101 – Requirements governing all A&H rate submissions
X X X (except for group disability income insurance)
X X X N/A N/A
4. Ins 4102 to 4106 – Specific rate submission requirements
4104 4103 4106 4102 4106 4105 4106 4106
Purpose X X X X X X X X Applicability X X X X X X X X Definitions –
Actuarial certification X X X X X X X X Actuarial memo X X X X X X X X Anticipated durational loss ratio
N/A X N/A N/A N/A N/A N/A N/A
Anticipated loss ratio X X X X X X X X Blanket A&H insurance N/A N/A X N/A X N/A X X
July 30, 2012
Tab D - 3
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
Case characteristics X X N/A N/A N/A X N/A N/A Carrier X X N/A N/A N/A X N/A N/A Consumer Price Index – Urban
N/A N/A N/A X N/A N/A N/A N/A
Covered Person X X N/A N/A N/A N/A N/A N/A Durational medical loss ratio
X X X X X X X X
Earned premium X (defined by ref. to CFR)
X (defined by ref. to CFR)
X (not defined by reference to CFR)
X (defined by ref. to CFR)
X (not defined by reference to CFR)
X (not defined by ref. to CFR)
X (not defined by reference to CFR)
X ( not defined by reference to CFR)
Eligible employee X X N/A N/A N/A X N/A N/A Employee X X N/A N/A N/A X N/A N/A Enrolled employee X X N/A N/A N/A X N/A N/A Expense based health coverage
N/A N/A N/A X N/A N/A N/A N/A
Group supplemental health insurance
N/A N/A X N/A X N/A X X
Health coverage X X N/A N/A N/A X N/A N/A High average premium forms
N/A N/A N/A X N/A N/A N/A N/A
Incurred claims X (defined by ref. to CFR)
N/A X (not defined by reference to CFR)
X (defined by ref. to CFR)
X (not defined by reference to CFR)
X (not defined by ref. to CFR)
X (not defined by reference to CFR)
X (not defined by reference to CFR)
Inflation index N/A N/A N/A X N/A N/A N/A N/A List bill N/A X N/A N/A N/A N/A N/A N/A
July 30, 2012
Tab D - 4
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
Low average premium form
N/A N/A N/A X N/A N/A N/A N/A
Medical loss ratio X (defined by reference to CFR)
X (defined by reference to CFR)
X (not defined by reference to CFR)
X (defined by reference to CFR)
X (not defined by reference to CFR)
X (not defined by reference to CFR)
X (not defined by reference to CFR)
X (not defined by reference to CFR)
Premium N/A X N/A N/A N/A X N/A N/A Rate N/A X N/A N/A N/A X N/A N/A Small/large employer X X N/A N/A N/A X N/A N/A Small/large/stop loss employer carrier
X X N/A N/A N/A X N/A N/A
Small employer health insurance plan
N/A X N/A N/A N/A N/A N/A N/A
Tier or tier membership X X X X X X X X Submission Requirements N/A N/A X X X N/A X X
(a) Actuarial memorandum for (1) new policy forms and (2) rate revision requests
X X X X X
(b) Records of earned premiums, incurred claims and reserves
X X X X X
(c) Credibility of experience
X X X X X
July 30, 2012
Tab D - 5
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
(d) Consideration of adjustments to anticipated loss ratio
X X X X X
(e) Reconciliation of data for adjustments and anticipated loss ratio
X X X X X
(f) Limit on rate variation X X X X X (g) Disclosure of
alternative policies with lower expenses
X X X X X
(h) Guaranteed issue of alternative policies in (g) on renewal basis
X X X X X
(i) No exclusion or variation of benefits based on allowable rating factor
N/A X N/A N/A N/A
(j) Requirement to provide notice of availability of coverage in high risk pool
N/A X N/A N/A N/A
(k) Content of high risk pool notices
N/A X N/A N/A N/A
Underwriting and Issue Requirements
Small group N/A X N/A N/A N/A N/A N/A N/A
July 30, 2012
Tab D - 6
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
(a) Small employer carrier (1) shall make all plans available for purchase, (2) shall not offer discontinued coverage, (3) may limit groups of 1 to specified time periods and (4) may refuse to issue or renew coverage based on failure to meet minimum participation reqs.
(b) Minimum participation standards
(c) Minimum participation not to include as eligible employees those declining coverage and included on dependent’s plan
(d) Allowable case characteristics (1) age, (2) number of employees and (3) industry
July 30, 2012
Tab D - 7
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
(e) Approximation of allowable case characteristics
(f) Rates not to be changed during policy year
Large group X N/A N/A N/A N/A N/A N/A N/A (a) Report to Department
of declinations and increases larger than change in plan rate plus 10%
(b) Report to include (1) policyholder ID number, (2) number of employees and covered lives for current and preceding years and (3) reason for declination or rate increase
(c) Carriers must specify case characteristics used to vary rates
(d) Detail regarding each case characteristic
Stop loss N/A N/A N/A N/A N/A X N/A N/A
July 30, 2012
Tab D - 8
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
(a) Report to Department of declinations and increases larger than 20%
(b) Report to include (1) policyholder ID number, (2) number of employees and covered lives for current and preceding years and (3) reason for declination or rate increase
(c) Carriers only to use allowable case characteristics
(d) Case characteristics limited to (1) age, (2) number of employees and (3) industry
(e) Approximation of allowable case characteristics
(f) Acceptable approximation methods
July 30, 2012
Tab D - 9
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
Loss Ratio Standards for Policy Forms
X (85%) X (80%) X (45% to 60% depending on renewability)
X (70% for standard forms; % of standard ratio for low and high average prem. forms)
X (45% to 60% depending on renewability)
N/A X (45% to 60% depending on renewability)
X (45% to 60% depending on renewability)
July 30, 2012
Tab D - 10
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
Loss Ratio Standards for Rate Revisions
• Revised rate for open block forms permitted if certain criteria met
• Loss ratios to be adjusted for closed block so that no additional revenue for administration is allowed unless support is provided demonstrating increased administration costs
• Failure to file rate revisions annually limits carrier to increase of one year of experience deviations; no rate increases to recoup revisions disallowed previously
• Not permitted to use rate revisions to recoup prior year’s losses
N/A N/A X X X N/A X X
July 30, 2012
Tab D - 11
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
Requirements for rates for franchise insurance
N/A N/A N/A X N/A N/A N/A N/A
Additional requirements for individual coverage subject to 420-G
N/A N/A N/A X N/A N/A N/A N/A
Rate filing standards (filings to include:)
X X N/A N/A N/A X N/A N/A
Large/small group • Calculation of market
rate • Calculation of plan rate • Application of
allowable case characteristics
• Supporting documentation
• Annual filing required • Interim filing permitted
for rate adjustments
July 30, 2012
Tab D - 12
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
Stop loss • Formulas/assumptions
used to calculate premiums
• Expected claims costs • Use of morbidity and
mortality tables • Commission rates for
producers • Expected loss ratio by
duration • Anticipated loss ratio
shorter of lifetime of block or 20 years
• Methods used for making projections
• Actual rates or formulas sufficient to calculate rates
• Annual filing required • Interim filing permitted
for rate adjustments
Renewal requirements • Guaranteed renewal
X X N/A N/A N/A N/A N/A N/A
July 30, 2012
Tab D - 13
Regulatory Provision Market Segment Large
Group Small Group
Group Supp.
Indiv./ Franch.
Blanket Stop Loss
Long-Term Care
Medicare Supp
Disclosure • Rate disclosure form to
be provided with each premium rate quote that includes health coverage plan rate for coverage elected and any adjustments for allowable case characteristics
N/A X N/A N/A N/A N/A N/A N/A
Notice Requirements • Notice of eligibility for
coverage with high risk pool (using approved notice)
• Copy of notice to high risk pool
X X N/A N/A N/A N/A N/A N/A